Basic Information
| Provider Information | |||||||||
| NPI: | 1750612669 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MULLICAN | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | NEWTON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 S EUCLID AVE | ||||||||
| Address2: | CB 8072 | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143629123 | ||||||||
| FaxNumber: | 3147473338 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 S KINGSHIGHWAY BLVD | ||||||||
| Address2: | DEPT EMERGENCY MEDICINE | ||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3143629123 | ||||||||
| FaxNumber: | 3147473338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2010 | ||||||||
| LastUpdateDate: | 11/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 2010010952 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 424152601 | 05 | MO | MEDICAID |